Vomiting in children ;29; Pediatr. Rev. Latha Chandran and Maribeth Chitkara Vomiting in Children: Reassurance, Red Flag, or Referral?

Transcription

1 Vomiting in children ;29; Pediatr. Rev. Latha Chandran and Maribeth Chitkara Vomiting in Children: Reassurance, Red Flag, or Referral?

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3 Vomiting in children Nausea: The unpleasant sensation of the imminent need to vomit, usually referred to the throat or epigastrium; a sensation that may or may not ultimately lead to the act of vomiting. Vomiting:Forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature. Regurgitation:The act by which food is brought back into the mouth without the abdominal and diaphragmatic muscular activity that characterizes vomiting

4 Vomiting in children The process is coordinated by the vomiting center in the central nervous system. The vomiting center receives sensory input from the vestibular nucleus (cranial nerve VIII), the GI tract via vagal afferents (cranial nerve X), and the bloodstream via the area postrema, also known as the chemoreceptor (or chemoreceptive) trigger zone. The stereotypic behavior sassociated with emesis area result of output from the vomiting center through vagal, phrenic, and sympathetic nerves.

5 Vomiting in children Vomiting can be classified according to its nature and cause as well as by the character of the vomitus. The nature of the vomiting may be projectile or nonprojectile. Projectile vomiting refers to forceful vomiting and may indicate increased intracranial pressure, especially if it occurs early in the morning. Projectile vomiting also is a classic feature of pyloric stenosis. Nonprojectile vomiting is seen more commonly in gastroesophageal reflux.

6 Vomiting in children Emesis often is classified based on its quality: the vomitus may be bilious, bloody, or nonbloody and nonbilious.

7 Vomiting in children Emesis originating from the stomach usually is characterized as being clear or yellow and often contains remnants of previously ingested food, Emesis that is dark green is referred to as bilious because it indicates the presence of bile, (intestinal obstruction beyond the duodenal ampulla of Vater, where the common bile duct empties). The presence of blood in the emesis, also known as hematemesis, indicates acute bleeding from the upper portion of the GI tract, as can occur with gastritis, Mallory-Weiss tears, or peptic ulcer disease.

8 Vomiting in children Coffee ground-like material often is representative of an old GI hemorrhage because blood darkens to a black or dark-brown color when exposed to the acidity of the gastric secretions. The more massive or proximal the bleeding, the more likely it is to be bright red.

9 Vomiting in children

10 Vomiting in children A variety of organic and nonorganic disorders can be associated with vomiting, The primary care practitioner needs to remember that vomiting does not localize the problem to the GI system in young infants but can be a nonspecific manifestation of an underlying systemic illness such as a urinary tract infection, sepsis, or an inborn error of metabolism.

11 Differential Diagnosis of Vomiting by Systems I. GASTROINTESTINAL. -Esophagus: Stricture, web, ring, atresia, tracheoesophageal fistula, achalasia, foreign body, -Stomach: pyloric stenosis, web, duplication, peptic ulcer, gastroesophageal reflux, -Intestine: duodenal atresia, foreign body, bezoar, pseudo-obstruction, necrotizing enterocolitis -Colon: Hirschsprung disease, imperforate anus, foreign body, bezoar

12 Differential Diagnosis of Vomiting by Systems Acute gastroenteritis Helicobacter pylori infection Parasitic infections: ascariasis, giardiasis, Appendicitis Celiac disease Milk/soy protein allergy syndrome Inflammatory bowel disease Pancreatitis Cholecystitis or cholelithiasis Infectious and noninfectious hepatitis Peritonitis, Trauma: Duodenal hematoma

13 Differential Diagnosis of Vomiting by Systems II. Neurologic Tumor, Cyst, Cerebral edema, Hydrocephalus, Migraine headache, Abdominal migraine, Seizure, Meningitis,

14 Differential Diagnosis of Vomiting by Systems III. Endocrine Diabetic ketoacidosis Adrenal insufficiency

15 Differential Diagnosis of Vomiting by Systems IV. Renal Obstructive uropathy: Ureteropelvic junction obstruction, hydronephrosis, nephrolithiasis Renal insufficiency Glomerulonephritis Urinary tract infection Renal tubular acidosis

16 Differential Diagnosis of Vomiting by Systems V. Metabolic Galactosemia Hereditary fructosemia Amino acidopathy Organic acidopathy Urea cycle defects Fatty acid oxidation disorders Lactic adidosis Lysosomal storage disorders Peroxisomal disorders

17 Differential Diagnosis of Vomiting by Systems VI. Respiratory Pneumonia Sinusitis Pharyngitis

18 Differential Diagnosis of Vomiting by Systems VII. Miscelaneous Sepsis syndromes Pregnancy Rumination Bulimia Psychogenic Cyclic vomiting syndrome Overfeeding Superior mesenteric artery Medications/vitamin/drug toxicity Child abuse

19 Diagnosis by Age

20 Diagnosis by Age

21 Vomiting in Infancy Vomiting in the first few days after birth may be a sign of serious pathology. Bilious emesis is suggestive of congenital obstructive GI malformations, such as duodenal/jejunal atresias, malrotation with midgut volvulus, meconium ileus or plugs, and Hirschsprung disease. Nonsurgical causes of bilious emesis include necrotizing enterocolitis and gastroesophageal reflux (GER).

22 Vomiting in Infancy: Intestinal Atresias Intestinal atresias Intestinal atresias are surgical emergencies and typically present within a few hours after birth, Duodenal atresia is a congenital obstruction of the second portion of the duodenum that occurs in 1 per 5,000 to 10,000 live births, Is associated with trisomy 21 in approximately 25% of cases. It is believed to be due to a failure of recanalization of the bowel during early gestation,

23 Vomiting in Infancy: Intestinal Atresias Infants present with clinical features of failure to tolerate feedings and bilious emesis shortly after birth. Due to the proximal nature of the obstruction, abdominal distention usually is not present. Plain abdominal radiographs may show a double bubble sign, which represents air in the stomach and proximal duodenum

24 Vomiting in Infancy: Intestinal Atresias

25 Vomiting in Infancy: Intestinal Atresias

26 Vomiting in Infancy: Intestinal Atresias More distal obstructions, such as jejunoileal atresias, typically present with bilious vomiting along with abdominal distention within the first 24 hours after birth. The cause of these atresias is believed to be a mesenteric vascular accident at some point during the course of gestation. Abdominal radiography may show dilated loops of small bowel with air-fluid levels, Urgent surgical correction is necessary for all types of intestinal atresias

27 Vomiting in Infancy: Intestinal Atresias

28 Vomiting in Infancy Beyond the Neonatal Period: Infantile Hypertrophic Pyloric Stenosis Infantile Hypertrophic Pyloric Stenosis Infants who have pyloric stenosis typically present to medical attention with persistent projectile nonbilious emesis between 2 and 6 weeks of age. Males, especially those who are firstborn, are affected approximately four times as often as females. The incidence is approximately 3 per 1,000 live births. The exact cause of pyloric stenosis remains unclear.

29 Vomiting in Infancy Beyond the Neonatal Period: Infantile Hypertrophic Pyloric Stenosis Pyloric stenosis usually is diagnosed by a typical history and physical findings. Inspection of the abdomen shortly after an infant feeding may reveal a peristaltic wave because the stomach muscles contract in an attempto pass ingested milk past the pylorus. A palpable olive in the mid-epigastric region represents the hypertrophic pyloric muscle and strongly supports the diagnosis of pyloric stenosis.

30 Vomiting in Infancy Beyond the Neonatal Period: Infantile Hypertrophic Pyloric Stenosis The classic presentation of IHPS is the threeto six-week-old baby who develops immediate postprandial, non-bilious, often projectile vomiting and demands to be re-fed soon afterwards (a "hungry vomiter").

31 Vomiting in Infancy Beyond the Neonatal Period: Infantile Hypertrophic Pyloric Stenosis Repeated episodes of vomiting of the gastric contents due to pyloric stenosis may result in characteristic electrolyte abnormalities, although serum electrolyte values may be normal if the patient is diagnosed in the early stages. The classic electrolyte abnormality is a hypochloremic hypokalemic metabolic alkalosis

32 Vomiting in Infancy Beyond the Neonatal Period: Infantile Hypertrophic Pyloric Stenosis When the diagnosis of pyloric stenosis is being considered, ultrasonography of the pyloric muscle can confirm the clinical suspicion, with sensitivity rates ranging from 85% to 100%. Pyloric muscle thickness of 4 mm or more and muscle length of 14 mm or more are diagnostic of pyloric stenosis, Surgical pyloromyotomy is the definitive treatment of pyloric stenosis and is being performed laparoscopically at many centers.

33 Vomiting in Infancy Beyond the Neonatal Period: Infantile Hypertrophic Pyloric Stenosis

34 Vomiting in Infancy Beyond the Neonatal Period: Infantile Hypertrophic Pyloric Stenosis

35 Vomiting in children: Intracranial Hypertension Brain tumors and other intracranial masses can cause nausea, vomiting, or both, by increasing the intracranial pressure at the area postrema of the medulla. Several characteristics suggest tumor-associated emesis, such as triggering emesis by an abrupt change in body position, neurogenic nausea and other neurologic symptoms such as headache or focal neurologic deficit; these signs and symptoms may be subtle.

36 Vomiting in children: Intracranial Hypertension Idiopathic intracranial hypertension refers to increased intracranial pressure (ICP) with normal cerebrospinal fluid (CSF) content, normal neuroimaging, the absence of neurologic signs except cranial nerve VI palsy, and no known cause. The clinical manifestations of idiopathic intracranial hypertension vary with age. Younger children, for example, who cannot complain of headache or visual impairment, may present with irritability, sleep, or behavior disturbance. In older children, headache is a more common chief complaint in older children and frequently is described as being pulsatile, occasionally awakening the child from sleep. Associated nausea or vomiting may be present, as may neck or retroocular pain that is worse with eye movement.

37 Vomiting in children: SMAS Superior Mesenteric Artery Syndrome Superior mesenteric artery (SMA) syndrome, otherwisem (Wilkie syndrome or cast syndrome), is a functional upper intestinal obstructive condition. Normally, the SMA forms a 45-degree angle, with the abdominal aorta at its origin and the third portion of the duodenum crossing between the two structures.0 When the angle between the SMA and the aorta is narrowed to less than 25 degrees, the duodenum may become entrapped and compressed. This condition most commonly is described in patients who have experienced rapid weight loss, immobilization in a body cast, or surgical correction of spinal deformities.

38 Vomiting in children: SMAS SMA syndrome typically presents with epigastric abdominal pain, early satiety, nausea, and bilious vomiting. Patients experience worsening pain in the supine position, which may be relieved in the prone or knee-chest position.

39 Vomiting in children: SMAS Conservative initial management of SMA syndrome focuses on gastric decompression, followed by the establishment of adequate nutrition and proper positioning after meals. Placement of an enteral feeding tube distal to the obstruction or parenteral nutrition may be needed in severe cases. Surgical correction with a duodenojejunostomy is a last resort.

40 Rumination Rumination is the repeated and painless regurgitation of ingested food into the mouth beginning soon after food intake. The food is re-chewed and swallowed or spit out. Symptoms do not occur during sleep and do not respond to the standard treatment of GER. To qualify for the diagnosis, symptoms must be present for longer than 8 weeks. Rumination is not associated with retching and often is viewed as a behavioral entity, typically seen in mentally retarded children, neonates during prolonged hospitalization, and children and infants who have GER.

41 Rumination Rumination also has been described in cases of child neglect and in older children and adolescents who have bulimia or are depressed. One third of affected individuals have underlying psychological disturbances. The management of rumination involves a multidisciplinary approach, with a primary focuson behavioral therapy and biofeedback. Occasionally, tricyclic antidepressants and nutritional support may be necessary.

42 General Principles in the Management of Vomiting Therapy to alleviate vomiting should be directed at the specific cause, when possible, Gastrointestinal obstructions should be corrected, Management of nonsurgical causes of vomiting include steps to correct fluid and electrolyte imbalances that result from prolonged or excessive vomiting and to identify and treat the underlying disorder causing the symptom,

43 General Principles in the Management of Vomiting Although the previously cited guidelines do not recommend the routine use of antiemetic drugs in the management of patients who have acute gastroenteritis, unique situations may warrant their use. If the cause of the vomiting is unclear, antiemetics are contraindicated.

44 General Principles in the Management of Vomiting A newer class of antiemetics is the 5HT3-receptor antagonists, ondansetron and granisetron. The 5HT3 blockade occurs both at the enteric level and at the chemoreceptor trigger zone. These drugs, unlike the phenothiazines and antihistamines, do not have central nervous system adverse effects, making them more attractive options. The 5HT3-receptor antagonists have been approved for the management of chemotherapy-induced nausea and vomiting and for pregnancy-associated and postoperative vomiting in adults.

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